Prospective Reviews

Review for Medical Necessity of a treatment plan, procedure, length of stay, level of care, discharge plan of future or ongoing services. Additional surgical evaluations or out of network issues may also be addressed.

Review of an ongoing service to determine its ongoing Medical Necessity, treatment plan, procedure, length of stay, level of care, discharge plan of future or ongoing services.

Review of medical records after completing services concerning Medical Necessity of the treatment plan, appropriate setting, and proper length of stay.

Type of coverage determination request whereby a member asks the health plan to cover a non-formulary medication or amend the plan's usage management restrictions placed on the medication.

Also known as Peer to Peer Conversations. The reviewer contacts the member's provider to discuss the medical/surgical evaluation on particular concerns addressed in the initial review, including Medical Necessity of treatment, appropriateness of treatment, proper length of stay, and discharge planning.

CPHCR is a certified utilization review entity (CRE) conducting utilization review (UR) for services on behalf of Pennsylvania managed care plans, to include Act 68 internal complaint and grievance appeals processing and to determine external grievance appeals received from consumers and providers regarding medical necessity and appropriateness of health services decision by managed care plans. 

CPHCR is certified by URAC to review a written or verbal request by a prescriber, ordering provider, or consumer to contest an organizational determination that may have been denied or reduced.

Review of a particular issue, service, or current practice that may involve evaluating criteria or guidelines. It may similarly include researching literature and drafting case or treatment specific guidelines for health plans.

CPHCR conducts audits that include any sequence of a Clinical Treatment Record Review, Claims Screening, and/or Compliance Program Audits.

CPHCR can provide your agency with licensed physicians to support your initial utilization management reviews as well as internal appeals.